U.S. Naval Sea Cadet Corps U.S. Navy League Cadet Corps

U.S. NAVAL SEA CADET CORPS FOR OFFICIAL USE ONLY U.S. NAVY LEAGUE CADET CORPS REPORT OF MEDICAL EXAM INSTRUCTIONS Acceptance criteria for applicants the Naval Sea Cadet Corps/Navy League Cadet Corps (NSCC/NLCC) are listed on the reverse side. No one will be denied admission to the program due to a medical disability, however participation may be limited if the cadet is not able to meet the medical standards necessary to FULLY participate in training activities involving strenuous physical exercise and activities such as orientation in fighting shipboard fires in often hot and humid environments. The examiner should list any condition(s) that could interfere with full, unrestricted, participation in the NSCC/NLCC. Conditions that will or are likely to require treatment particularly unresolved injuries and recurrent illness must be listed. The history of immunization should be verified to the satisfaction of the medical examiner. A licensed medical provider must complete this examination. 1. UNIT INFORMATION 1a. Unit Name 1b. Region

2. PERSONNEL INFORMATION 2a. Last Name 2b. First Name 2c. MI 2d. Social Security Number

2e. Age 2f. Date of Birth (DD MMM YY) 2g. Sex 2h. Parent/Guardian Name (cadets only)  Male  Female 2i. Home Address 2j. City 2k. State 2l. Zip Code + 4

2m. Home Phone 2n. Date of Physical Examination (DD MMM YY) 2o. Location of Physical Examination

4. CLINICAL EVALUATION

Anatomy Normal Abnormal NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment) 4a. Head, Face, Neck, and Scalp   4b. Nose   4c. Sinuses   4d. Ears – General (Internal and External Canals)   4e. Drum (Perforation)   4f. Eyes- General   4g. Ophthalmoscopic   4h. Pupils (Equality and Reaction)   4i. Heart (Thrust, Size, Rhythm, and Sounds)   4j. Lungs and Chest   4k. Abdomen and Viscera (Include Hernia)   4l. External Genitalia (Genitourinary)   4m. Upper Extremities   4n. Lower Extremities   4o. Feet   4p. Spine and other Musculoskeletal  

5. LABORATORY FINDINGS (only required for those with a history of urinary tract infections or anemia, enter N/A if tests were not administered) 5a. Urinalysis 5b. Blood (1) Albumin: (2) Sugar: (1) Hemoglobin: (2) Hematocrit:

6. MEASUREMENTS AND OTHER FINDINGS 6a. Height 6b. Weight 6c. Obese 6d. Pulse 6e. Blood Pressure inches lbs.  Yes  No (1) Systolic: (2) Diastolic: 6f. Audiogram (if available) 6g. Wears Glasses 6h. Wears Contacts 6i. Uncorrected Vision HZ 500 1000 2000 3000 4000 6000  Yes  No  Yes  No (1) Left: 20/ (2) Right: 20/ Right 6k. Color Vision Left 6l. Other Findings (if more room is needed, continue on reverse)

NSCADM 021 (REV 05/09) PREVIOUS EDITIONS ARE OBSOLETE REPORT OF MEDICAL EXAM 7. CLINICAL SCREENING (Please check if the patient has any of the following conditions and whether it will affect the ability to participate in NSCC/NLCC activities.)

Condition(s) Pre-Existing NOTES: (Describe every condition in detail. Enter pertinent item number before each comment)

7a. Seizure or convulsion disorder  Yes  No 7b. Asthma  Yes  No 7c. Symptomatic/recurring orthopedic injury  Yes  No 7d. Diabetes, Type I  Yes  No 7e. Diabetes, Type II  Yes  No 7f. Hypersensitivity to Food  Yes  No 7g. Insect bites/stings sensitivity  Yes  No 7h. Head injuries resulting in residual impairment  Yes  No 7i. Neurological Impairment  Yes  No 7j. History of recurring loss of consciousness  Yes  No 7k. History of debilitating motion sickness  Yes  No 7l. Sleepwalking  Yes  No 7m. Bedwetting  Yes  No 8. NOTES, REMARKS, AND OTHER FINDINGS (Use additional sheets of paper if needed)

9. MEDICAL PROVIDER ENDORSEMENT (Check all that apply): I have reviewed the data above, reviewed the patient’s medical history form and make the following recommendations for his/her participation in the NSCC/NLCC 9a.  CLEARED WITHOUT RESTRICTIONS 9b.  Cleared AFTER further evaluation or treatment for: 9c.  Cleared for LIMITED participation  Not cleared for (specify activities):  Cleared only for (specify activities): Reasons: 9d.  NOT CLEARED FOR PARTICIPATION

Reasons: 9e.  OTHER RECOMMENDATIONS  Recommend close monitoring during conditioning because of weight/fitness/other.  Recommend restrictions or monitoring of weight loss/gain or fitness concerns.  Recommend participations under following condition(s):  Other:

10. MEDICAL PROVIDER 10a. Name of Medical Provider (Type or Print) or Medical Provider Stamp 10b. Signature (MD, DO, PN, PA) 10c. Date (DD MMM YY)

10b. Medical Provider Address 10c. City 10c. State 10c. Zip Code +4 10c. Phone

NSCADM 021 (REV 05/09), Reverse PREVIOUS EDITIONS ARE OBSOLETE